Information Collection

Certification Regarding Drug-Free Workplace Requirements

IC 45633 under ICR 201004-0581-006 · OMB 0581-0240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0581-0240 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1049 Certification Regarding Drug-Free Workplace Requirements	Form and Instruction
AD-1049 Certification Regarding Drug-Free Workplace Requirements Cert. re Drug-Free Workplace Reqmts. AD-1049.pdf www.rurdev.usda.gov/rbs/coops/ad1049.pdf	Form and Instruction

IC Title:

Certification Regarding Drug-Free Workplace Requirements

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AD-1049	Certification Regarding Drug-Free Workplace Requirements	Cert. re Drug-Free Workplace Reqmts. AD-1049.pdf	http://www.rurdev.usda.gov/rbs/coops/ad1049.pdf	Yes	No	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-25	25
Annual IC Time Burden (Hours)	-5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.